ARCHIVAL USE ONLY Refer to the Online Handbook for current policy

Mental Health and Substance Abuse Services Substance Abuse Day Treatment

DIVISION OF HEALTH CARE FINANCING WISCONSIN MEDICAID AND BADGERCARE PROVIDER SERVICES 6406 BRIDGE ROAD MADISON WI 53784 Jim Doyle Governor Telephone: 800-947-9627 Helene Nelson State of Wisconsin 608-221-9883 dhfs.wisconsin.gov/medicaid Secretary Department of Health and Family Services dhfs.wisconsin.gov/badgercare DATE: March 1, 2006 M E M O R A N D U M TO: FROM: SUBJECT: Wisconsin Medicaid-Certified Substance Abuse Day Treatment Providers Mark Moody, Administrator Division of Health Care Financing Wisconsin Medicaid Mental Health and Substance Abuse Services Handbook with Substance Abuse Day Treatment section The Division of Health Care Financing is pleased to provide a copy of two sections of the Mental Health and Substance Abuse Handbook. The General Information section of the handbook articulates current Medicaid policies found in Wisconsin Administrative Code, HFS 101-108, as they apply to mental health and substance abuse services. The Substance Abuse Day Treatment Services section incorporates current Medicaid substance abuse policy information into a single reference source. This section replaces Part H, Division IV, the AODA Day Treatment handbook (issued July 1989), and the following service-specific Wisconsin Medicaid and BadgerCare Updates: The July 2003 Update (2003-78), titled Changes to local codes, paper claims, and prior authorization for substance abuse day treatment services as a result of HIPAA. The April 2004 Update (2004-34), titled Medical Record Documentation Requirements for Mental Health and Substance Abuse Services. The December 2004 Update (2004-88), titled Coverage of Mental Health and Substance Abuse Services Provided Via Telehealth. The January 2005 Update (2005-08), titled Wisconsin Medicaid Accepting Prior Authorization Requests Via the Web for Additional Service Areas. All-Provider Publications Providers are reminded to retain their all-provider publications. The revised Mental Health and Substance Abuse Services Handbook sections does not replace these publications. Additional Copies of Publications The Wisconsin Medicaid Web site, dhfs.wisconsin.gov/medicaid/, contains additional information for all Medicaid providers, service-specific information, and electronic versions of the Mental Health and Substance Abuse Services Handbook and the All-Provider Handbook. Providers who have questions about the information in this handbook may call Provider Services at (800) 947-9627 or (608) 221-9883.

Contacting Wisconsin Medicaid Web Site dhfs.wisconsin.gov/ The Web site contains information for providers and recipients about the following: Program requirements. Publications. Forms. Maximum allowable fee schedules. Professional relations representatives. Certification packets. Available 24 hours a day, seven days a week Automated Voice Response System (800) 947-3544 (608) 221-4247 The Automated Voice Response system provides computerized voice responses about the following: Recipient eligibility. Prior authorization (PA) status. Claim status. Checkwrite information. Available 24 hours a day, seven days a week Provider Services (800) 947-9627 (608) 221-9883 Available: Resolving claim denials. Provider certification. Correspondents assist providers with questions about the following: Clarification of program requirements. Recipient eligibility. Division of Health Care Financing Electronic Data Interchange Helpdesk 8:30 a.m. - 4:30 p.m. (M, W-F) 9:30 a.m. - 4:30 p.m. (T) Available for pharmacy services: 8:30 a.m. - 6:00 p.m. (M, W-F) 9:30 a.m. - 6:00 p.m. (T) (608) 221-9036 e-mail: wiedi@dhfs.state.wi.us Correspondents assist providers with technical questions about the following: Electronic transactions. Companion documents. Provider Electronic Solutions software. Available 8:30 a.m. - 4:30 p.m. (M-F) Web Prior Authorization Technical Helpdesk (608) 221-9730 Correspondents assist providers with Web PA-related technical questions about the following: User registration. Submission process. Passwords. Available 8:30 a.m. - 4:30 p.m. (M-F) Recipient Services (800) 362-3002 (608) 221-5720 Correspondents assist recipients, or persons calling on behalf of recipients, with questions about the following: Recipient eligibility. General Medicaid information. Finding Medicaid-certified providers. Resolving recipient concerns. Available 7:30 a.m. - 5:00 p.m. (M-F)

TTable of Contents Preface... 3 Provider and Recipient Information... 5 Provider Certification... 5 Copayment... 5 Managed Care Coverage for Day Treatment Services... 5 Covered Services... 7 Program Admission Requirements... 7 Sessions Requirements... 7 Covered Services... 7 Services Provided Via Telehealth... 8 Reimbursement Limitations... 8 Noncovered Services... 8 Special Circumstances... 8 Documentation Requirements... 8 Prior Authorization... 9 Services Requiring Prior Authorization... 9 Prior Authorization Criteria... 9 Procedures for Obtaining Prior Authorization... 9 Backdating Substance Abuse Prior Authorization Requests... 9 Claims Submission... 11 Coordination of Benefits... 11 Diagnosis Codes... 11 Procedure Codes... 11 Place of Service Codes... 11 837 Health Care Claim: Professional... 11 CMS 1500... 11 Reimbursement... 12 Appendix... 13 1. Medicaid Certification Requirements for Substance Abuse Day Treatment Services... 15 2. Allowable Procedure Code and Modifiers for Substance Abuse Day Treatment Services... 17 3. Allowable Place of Service Codes for Substance Abuse Day Treatment Services... 19 4. Prior Authorization Request Form (PA/RF) Completion Instructions for Substance Abuse Day Treatment Services... 21 5. Sample Prior Authorization Request Form (PA/RF) for Substance Abuse Day Treatment Services... 25 PHC 1336

6. Treatment Criteria for Substance Abuse Day Treatment (Adult): Severity of Illness... 27 7. Treatment Criteria for Substance Abuse Day Treatment Program (Adolescent): Severity of Illness... 29 8. Treatment Criteria for Substance Abuse Day Treatment Program (Adult and Adolescent): Intensity of Service... 31 9. Prior Authorization/Substance Abuse Day Treatment Attachment (PA/SADTA) Completion Instructions... 33 10. Prior Authorization/Substance Abuse Day Treatment Attachment (PA/SADTA) (for photocopying)... 37 11. CMS 1500 Claim Form Instructions for Substance Abuse Day Treatment Services... 43 12. Sample CMS 1500 Claim Form for Substance Abuse Day Treatment Services... 49 13. Sample CMS 1500 Claim Form for Substance Abuse Day Treatment Services, Biller Only Providers... 51 14. Mental Health and Substance Abuse Services Documentation Requirements... 53 Index... 55

Preface Wisconsin Medicaid and BadgerCare mental health and substance abuse services publications apply to fee-forservice Medicaid providers. The information in these publications apply to Medicaid and BadgerCare programs for recipients on fee-for-service Medicaid. Medicaid is a joint federal and state program established in 1965 under Title XIX of the federal Social Security Act. Wisconsin Medicaid is also known as the Medical Assistance Program, WMAP, MA, Title XIX or T19. BadgerCare extends Medicaid coverage through a Medicaid expansion under Titles XIX and XXI. The goal of BadgerCare is to fill the gap between Medicaid and private insurance without supplanting or crowding out private insurance. BadgerCare recipients receive the same health benefits as Medicaid recipients, and their health care is administered through the same delivery system. sections: Refer to the Online Claims Handbook Information. Coordination of Benefits. Wisconsin Medicaid and BadgerCare are administered by the Department of Health and Family Services (DHFS). Within the DHFS, the Division of Health Care Financing (DHCF) is directly responsible for managing Wisconsin Medicaid and BadgerCare. Unless otherwise specified, all information contained in this and other Medicaid publications pertains to services provided to recipients who receive care through fee-forservice. Refer to the Managed Care section of the All- Provider Handbook for information about statecontracted managed care organizations. Substance Abuse Day Treatment Section The information in the Substance Abuse Day Treatment section of this Mental Health and Substance Abuse Handbook applies to Division of Disability and Elder Services, Bureau of Quality Assurance-certified substance abuse day treatment service programs. Substance abuse day treatment providers should refer to the All-Provider Handbook, the General Information section of this handbook, and this section to find answers to policy-related questions. All-Provider Handbook All Medicaid-certified providers receive a copy of the All-Provider Handbook, which includes the following Certification and Ongoing Responsibilities. Covered and Noncovered Services. Informational Resources. Managed Care. Prior Authorization. Recipient Eligibility. Providers are required to refer to the All-Provider Handbook for more information about these topics. Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 3

Wisconsin Medicaid and BadgerCare Web Sites Publications (including provider handbooks and Wisconsin Medicaid and BadgerCare Updates), maximum allowable fee schedules, telephone numbers, addresses, and more information are available on the following Web sites: dhfs.wisconsin.gov/medicaid/. dhfs.wisconsin.gov/badgercare/. Publications Medicaid publications apply to both Wisconsin Medicaid and BadgerCare. Publications interpret and implement the laws and regulations that provide the framework for Wisconsin Medicaid and BadgerCare. Medicaid publications provide necessary information about program requirements. Legal Framework The following laws and regulations provide the legal framework for Wisconsin Medicaid and BadgerCare: Federal Law and Regulation: Law United States Social Security Act; Title XIX (42 US Code ss. 1396 and following) and Title XXI. Regulation Title 42 CFR Parts 430-498 and Parts 1000-1008 (Public Health). Wisconsin Law and Regulation: Law Wisconsin Statutes: 49.43-49.499 and 49.665. Regulation Wisconsin Administrative Code, Chapters HFS 101-109. Laws and regulations may be amended or added at any time. Program requirements may not be construed to supersede the provisions of these laws and regulations. 4 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

WWisconsin Medicaid strongly recommends that providers verify the recipient s current enrollment in an MCO before providing services. Provider and Recipient Information PProvider Certification To be reimbursed for providing substance abuse day treatment services to Medicaid recipients, a provider is first required to be certified by the Department of Health and Family Services (DHFS), Division of Disability and Elder Services (DDES) for substance abuse day treatment under HFS 75.12, Wis. Admin. Code. For information regarding this certification, write to the following address: Division of Disability and Elder Services Bureau of Quality Assurance Program Certification Unit 2917 International Ln Ste 300 Madison WI 53704 (608) 243-2025 A provider ARCHIVAL meeting DHFS, DDES certification USE ONLY may initiate Medicaid substance abuse day treatment provider certification, as outlined HFS 105.23, Wis. Admin. Code, by doing one of the following: 1. Downloading mental health agency certification materials from the Medicaid Web site. 2. Calling Provider Services at (800) 947-9627 or (608) 221-9883. 3. Writing to the following address: Wisconsin Medicaid Provider Maintenance 6406 Bridge Rd Madison WI 53784-0006 Refer to the General Information section of this handbook for more information about provider certification, provider numbers, and provider responsibilities. Refer to the Certification and Ongoing Responsibilities section of the All-Provider Handbook for additional information. Copayment Providers are prohibited from collecting copayment from recipients receiving substance abuse day treatment services. Managed Care Coverage for Day Treatment Services State-contracted managed care organizations (MCOs) cover substance abuse day treatment services. Recipients enrolled in all statecontracted MCOs must receive substance abuse day treatment services through the MCO. Providers should check with the recipient s MCO for further information on coverage. Wisconsin Medicaid strongly recommends that providers verify the recipient s current enrollment in an MCO before providing services. Claims submitted to Wisconsin Medicaid for substance abuse day treatment services covered by MCOs will be denied. Provider/Recipient Information Refer to Appendix 1 of this section for more information about certification. Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 5

Provider/Recipient Information 6 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Covered Services The Substance Abuse Day Treatment section of the Mental Health and Substance Abuse Services Handbook contains information for providers of substance abuse day treatment services. scheduled number of sessions per day and week, with each recipient generally receiving a minimum of 12 hours of counseling per week and/or a minimum of 60 hours within a sixweek period of time. W Wisconsin Medicaid reimburses the first three hours of assessment and evaluation per recipient, per provider in a calendar year regarding the need for, and ability to benefit from, substance abuse day treatment. According to HFS 101.03(12m), Wis. Admin. Code, substance abuse day treatment means alcohol and other drug abuse treatment services provided by a provider certified under HFS 105.25, Wis. Admin. Code, to a recipient who, in the clinical judgment of a qualified treatment professional, is experiencing a problem with alcohol or other drugs and is willing to receive intensive services of a prescribed duration. These services may include assessment and evaluation, treatment planning, group and individual counseling, recipient education when necessary for effective ARCHIVAL treatment, and rehabilitative USE services ONLY to ameliorate or remove the disability and Refer restore effective to functioning. the Online Handbook Program for Admission current policy Requirements For admission to a substance abuse day treatment program, a recipient must be willing to participate; be detoxified from drugs or alcohol; have the ability to function in a semicontrolled, medically supervised environment; have a demonstrated need for structure and intensity of treatment that is not available in outpatient treatment; and be willing to participate in aftercare upon completion of treatment. Sessions Requirements A substance abuse day treatment service is a medically monitored, nonresidential substance abuse treatment service that consists of regularly scheduled sessions that may include individual and/or group counseling and case management, provided under the supervision of a physician. Services are provided in a Covered Services A covered service is a service, item, or supply for which Medicaid reimbursement is available when all program requirements are met. For a covered service to meet program requirements, the service must be provided by a qualified Medicaid-certified provider to an eligible recipient. In addition, the service must meet all applicable program requirements, including, but not limited to, medical necessity, prior authorization (PA), claims submission, prescription, and documentation requirements. The following services are covered under substance abuse day treatment: Assessment. Wisconsin Medicaid reimburses the first three hours of assessment and evaluation per recipient, per provider in a calendar year regarding the recipient s need for, and ability to benefit from, substance abuse day treatment. Substance abuse day treatment. Wisconsin Medicaid reimburses for intensive, short-term substance abuse treatment provided in a substance abuse day treatment program certified under HFS 105.25, Wis. Admin. Code, for recipients who need and want day treatment services. Refer to the Covered and Noncovered Services section of the All-Provider Handbook for more information about covered services, medical necessity, services that are not separately reimbursable, and emergency services. Covered Services Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 7

Covered Services Services Provided Via Telehealth Individual substance abuse day treatment services may be provided via Telehealth. Refer to the General Information section of this handbook for information about Telehealth requirements and claims submission. Reimbursement Limitations Wisconsin Medicaid does not reimburse the following services or circumstances in accordance with HFS 107.13(3m)(c), Wis. Admin. Code: Substance abuse day treatment services in excess of five hours per day are not reimbursable. Substance abuse day treatment services may not be billed as psychotherapy, substance abuse outpatient treatment, case management, occupational therapy or any other service modality except substance abuse day treatment. Reimbursement for substance abuse day treatment services may not include time devoted to meals, rest periods, transportation, recreation, or entertainment. Reimbursement for substance abuse day treatment assessment for a recipient is limited to three hours in a calendar year. Additional assessment hours shall be counted toward the mental health outpatient dollar or hour amount under HFS 107.13(2)(a)6, Wis. Admin. Code, before PA is required or the substance abuse outpatient dollar or hour limit under HFS 107.13(3)(a)4, Wis. Admin. Code, before PA is required. Noncovered Services The following services are not covered by Wisconsin Medicaid, in accordance with HFS 107.13(3m)(d), Wis. Admin. Code: Collateral interviews and consultations, except as provided in HFS 107.06(4)(d), Wis. Admin. Code. Time spent in the substance abuse day treatment setting by affected family members of the recipient. Substance abuse day treatment services billed under any other Medicaid service category, including substance abuse outpatient services, psychotherapy, occupational therapy, or case management. Substance abuse day treatment services which are primarily recreational or which are provided in non-medically supervised settings. These include, but are not limited to, sports activities, exercise groups, and activities such as crafts, leisure time, social hours, trips to community activities, and tours. Services provided to a substance abuse day treatment recipient which are primarily social or educational in nature. Educational sessions are covered as long as these sessions are part of an overall treatment program and include group processing of the information provided. Prevention or education programs provided as an outreach service or as case-finding. ARCHIVAL Day treatment USE provided ONLY in the recipient s home. Special Circumstances for current The following requirements policy apply specifically to substance abuse day treatment services: All substance abuse day treatment services require a physician prescription/ order. Wisconsin Medicaid reimburses the provision of services. Documenting the services provided is part of the provision of services. Documentation Requirements Refer to Appendix 14 of this section for documentation requirements for all mental health and substance abuse service providers, including substance abuse day treatment providers. For additional information regarding documentation requirements, refer to the General Information section of this handbook. All substance abuse day treatment services require a physician prescription/order. 8 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Prior Authorization WWhen assessing recipients who are 18 to 21 years old, providers are to use either the adolescent or adult criteria, depending on the individual recipient s circumstances. Providers are required to obtain prior authorization (PA) for the substance abuse day treatment services specified in this chapter. Authorization for these services must be received prior to providing the services. Refer to the General Information section of this handbook for general PA requirements. For more information about general PA forms and attachments and submitting PA requests, refer to the Prior Authorization section of the All-Provider Handbook. Services Requiring Prior Authorization Prior authorization is not required for the substance abuse assessment, the limit for which is three hours per recipient, per provider in a calendar ARCHIVAL year. USE ONLY Refer Prior authorization to the is required Online before providinghandbook any substance abuse day treatment services to or (608) 221-9883. a recipient following for the current assessment. policy Prior Authorization Criteria Prior authorization criteria for intensity of treatment and severity of illness have been developed for substance abuse day treatment by Wisconsin Medicaid and substance abuse providers. Appendices 6, 7, and 8 of this section contain treatment criteria for substance abuse day treatment services for adults and adolescents. When assessing recipients who are 18 to 21 years old, providers are to use either the adolescent or adult criteria, depending on the individual recipient s circumstances. Providers are required to refer to the appropriate treatment criteria when requesting PA. The criteria illustrate the factors that will be used in determining whether substance abuse day treatment is considered medically necessary by Wisconsin Medicaid. Wisconsin Medicaid reviews and adjudicates PA requests on a case-by-case basis. It is therefore essential that adequate, explicit clinical information be provided on each PA request. Procedures for Obtaining Prior Authorization Providers are required to submit both the Prior Authorization Request Form (PA/RF), HCF 11018, and the Prior Authorization/Substance Abuse Day Treatment Attachment (PA/ SADTA), HCF 11037, for substance abuse day treatment services. The completion instructions and a completed sample PA/RF are located in Appendices 4 and 5 of this section. The PA/RF can be obtained by contacting Provider Services at (800) 947-9627 The completion instructions and a copy of the PA/SADTA are located in Appendices 9 and 10 of this section for photocopying and may also be downloaded from the Medicaid Web site. Backdating Substance Abuse Prior Authorization Requests In certain cases, it is medically necessary to start a recipient in substance abuse day treatment within a short period of time following the initial assessment or completion of detoxification. Wisconsin Medicaid allows backdating of substance abuse day treatment PA requests up to five working days prior to the initial date that Wisconsin Medicaid receives the request, as long as backdating procedures are followed. Prior Authorization Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 9

Refer to the General Information section of this handbook for backdating procedures. Refer to the Prior Authorization section of the All-Provider Handbook for information on other circumstances affecting PA, such as determination of grant dates and service interruptions. Prior Authorization 10 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

H Healthcare Common Procedure Coding System (HCPCS) codes are required on all substance abuse day treatment claims. CTo receive reimbursement, claims and adjustment requests must be received by Wisconsin Medicaid within 365 days of the date of service (DOS). To receive reimbursement for services that are allowed by Medicare, claims and adjustment requests for coinsurance, copayment, and deductible must be received by Wisconsin Medicaid within 365 days of the DOS, or within 90 days of the Medicare processing date, whichever is later. Claims Submission For more information about exceptions to the claims submission deadline, Medicaid remittance information, adjustment requests, and returning overpayments, refer to the Claims Information section of the All- Provider Handbook. Coordination ARCHIVAL of Benefits USE ONLY Refer With few exceptions, to the Wisconsin Online Medicaid ishandbook the payer of last resort for any Medicaidcovered service. Therefore, the provider is required to make a reasonable effort to exhaust all existing other health insurance sources before submitting claims to Wisconsin Medicaid or to state-contracted managed care organizations. Refer to the Coordination of Benefits section of the All-Provider Handbook for more information about services that require other health insurance billing, exceptions, claims submission procedures for recipients with other health insurance, and the Other Coverage Discrepancy Report, HCF 1159. Diagnosis Codes All diagnoses must be from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding structure. Claims received without an allowable ICD-9-CM code are denied. Refer to Appendix 2 of this section for a list of allowable diagnosis code ranges for substance abuse day treatment services. Procedure Codes Healthcare Common Procedure Coding System (HCPCS) codes are required on all substance abuse day treatment claims. Claims or adjustments received without a HCPCS code are denied. Refer to Appendix 2 of this section for the allowable procedure code and modifiers. Place of Service Codes Allowable place of service codes for substance abuse day treatment are included in Appendix 3 of this section. 837 Health Care Claim: Professional Providers are encouraged to submit claims electronically since electronic claims submission usually reduces claim errors. Claims for substance abuse day treatment services may be submitted using the 837 Health Care Claim: Professional transaction except when submitting claims that require additional documentation. In these situations, providers are required to submit paper claims. Refer to the Informational Resources section of the All-Provider Handbook for more information about electronic transactions. CMS 1500 Paper claims for substance abuse day treatment services must be submitted using the CMS 1500 claim form dated 12/90. Wisconsin Medicaid denies claims for substance abuse day treatment services submitted on any paper claim form other than the CMS 1500. Claims Submission Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 11

Wisconsin Medicaid does not provide the CMS 1500 claim form. The form may be obtained from any federal forms supplier. Refer to Appendix 11 of this handbook for claim form instructions for substance abuse day treatment services. Appendices 12 and 13 are samples of claims for substance abuse day treatment services. Reimbursement Certified substance abuse day treatment providers are reimbursed at the lesser of the provider s usual and customary charge or the maximum allowable fee established by the Department of Health and Family Services. The maximum allowable fee is a comprehensive hourly rate that is paid for any allowable day treatment service regardless of which staff person provided the service or whether the service was a group or individual service. Hospitals that have certified substance abuse day treatment programs should not include the Medicaid charges associated with the day treatment cost center in the Medicare/ Medicaid Cost Report. Substance abuse day treatment services are not considered hospital outpatient services. HHospitals that have certified substance abuse day treatment programs should not include the Medicaid charges associated with the day treatment cost center in the Medicare/Medicaid Cost Report. Claims Submission 12 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Appendix Appendix Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 13

Appendix 14 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Appendix 1 Medicaid Certification Requirements for Substance Abuse Day Treatment Services This appendix outlines Wisconsin Medicaid certification requirements for substance abuse day treatment service providers. Prior to obtaining Wisconsin Medicaid certification, substance abuse day treatment providers are required to be certified by the Department of Health and Family Services (DHFS), Division of Disability and Elder Services (DDES), Bureau of Quality Assurance (BQA). County/tribal social or human services agencies that request billing-only status do not need to be certified by the DDES. The following terms are used in the table: Agency Providing the Service The agency whose staff actually performs the service. Agency Only Allowed to Bill the Service The agency that submits claims to Wisconsin Medicaid for the service. This agency does not perform the service but contracts with a provider to perform the service on the billing agency s behalf. The provider may be a certified program within the billing agency. Only a county/tribal social or human services agency can be a billing agency. The following table lists required provider numbers and definitions for agencies providing mental health and substance abuse services. Type of Provider Number Billing/Performing Provider Number Billing-Only Provider Number Type of Agency Agency Providing the Service Agency Only Allowed to Bill the Service Definitions for Provider Numbers Definition Issued to providers to allow them to identify themselves on claims as either the biller of services or the performer of services. ARCHIVAL services when contracting with USE a service performer. ONLY Refer to the Certification Online Requirements Handbook Specific Certification Division of Disability and Elder Services/Bureau of Quality Assurance The agency is required to obtain a Wisconsin DHFS certificate to provide substance abuse day treatment services as authorized under HFS 75.12, Wis. Admin. Code. Not required Issued to county/tribal social or human services agencies to allow them to serve as the biller of Wisconsin Medicaid The agency is required to do the following: Have a DDES, BQA certificate on file. Complete and submit a Mental Health and Substance Abuse Agency Certification Packet. The agency is required to complete and submit a Mental Health and Substance Abuse Agency Certification Packet to be a billingonly provider for substance abuse day treatment services. An allowable Medicaid performing provider is required to perform the service. Section of the Medicaid Mental Health/ Substance Abuse Agency Packet to Be Completed Substance Abuse Day Treatment Substance Abuse Day Treatment County/ Tribal Social or Human Services Agency? No Yes Type of Provider Number Assigned Day treatment (mental health/ substance abuse) billing/ performing provider number Day treatment (mental health/ substance abuse) billing provider number Appendix Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 15

Appendix 16 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Appendix 2 Allowable Procedure Code and Modifiers for Substance Abuse Day Treatment Services The following table lists the Healthcare Common Procedure Coding System (HCPCS) procedure code and modifiers that substance abuse day treatment providers are required to use when requesting prior authorization and submitting claims. HCPCS Code H2012 Description Behavioral health day treatment, per hour Program Modifier Code HF Substance abuse program Service Modifier Code Allowable ICD-9-CM Diagnosis Codes* None 303.90-303.91 304.00-304.01 304.10-304.11 304.20-304.21 304.30-304.31 304.40-304.41 304.50-304.51 304.60-304.61 304.70-304.71 304.80-304.81 304.90-304.91 305.00-305.01** Telehealth Services Covered? 305.20-305.21** 305.30-305.31** 305.40-305.41** Refer to the Online 305.50-305.51** Handbook 305.60-305.61** for current 305.70-305.71** policy Behavioral health day treatment, per hour HF Substance abuse program U6 Assessment 305.80-305.81** 305.90-305.91** Diagnosis code required, no restrictions For individual services only Prior Authorization Required? * ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification. The list of ICD-9-CM diagnosis codes for substance abuse day treatment is inclusive. However, not all Medicaid-covered substance abuse day treatment services are appropriate or allowable for all diagnoses. Wisconsin Medicaid bases approval of services on a valid diagnosis, acceptable substance abuse day treatment practice, and clear documentation of the probable effectiveness of the proposed service. ** An abuse diagnosis, as the only and primary diagnosis, is appropriate only for children or adolescents for substance abuse day treatment services. Yes Yes No Appendix Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 17

Appendix 18 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Appendix Appendix 3 Allowable Place of Service Codes for Substance Abuse Day Treatment Services The following table lists allowable place of service (POS) codes that substance abuse day treatment providers may use when submitting prior authorization requests and claims to Wisconsin Medicaid. Substance abuse day treatment services may be provided in the following POS by certified substance abuse day treatment programs only. Code Description 05 Indian Health Service Free-Standing Facility 06 Indian Health Service Provider-Based Facility 07 Tribal 638 Free-Standing Facility 08 Tribal 638 Provider-Based Facility 11 Office 22 Outpatient Hospital 50 Federally Qualified Health Center 71 State or Local Public Health Clinic 72 Rural Health Clinic Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 19

Appendix 20 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Appendix 4 Prior Authorization Request Form (PA/RF) Completion Instructions for Substance Abuse Day Treatment Services Wisconsin Medicaid requires certain information to enable Medicaid to authorize and pay for medical services provided to eligible recipients. Recipients are required to give providers full, correct, and truthful information for the submission of correct and complete claims for Medicaid reimbursement. This information should include, but is not limited to, information concerning eligibility status, accurate name, address, and Medicaid identification number (HFS 104.02[4], Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about Medicaid applicants and recipients is confidential and is used for purposes directly related to Medicaid administration such as determining eligibility of the applicant or processing provider claims for reimbursement. The Prior Authorization Request Form (PA/RF), HCF 11018, is used by Wisconsin Medicaid and is mandatory when requesting PA. Failure to supply the information requested by the form may result in denial of Medicaid payment for the services. Providers may submit PA requests, along with the Prior Authorization/Substance Abuse Day Treatment Attachment (PA/SADTA), HCF 11037, by fax to Wisconsin Medicaid at (608) 221-8616 or by mail to the following address: Wisconsin Medicaid Prior Authorization Ste 88 6406 Bridge Rd Madison WI 53784-0088 The provision of services that are greater than or significantly different from those authorized may result in nonpayment of the billing claim(s). SECTION I PROVIDER INFORMATION Element 1 Name and Address Billing Provider Enter the name and complete address (street, city, state, and zip code) of the billing provider. The name listed in this element must correspond with the Medicaid provider number listed in Element 4. No other information should be entered in this element, since it also serves as a return mailing label. Appendix Element 2 Telephone Number Billing Provider Enter the telephone number, including the area code, of the office, clinic, facility, or place of business of the billing provider. Element 3 Processing Type Enter processing type 136. The processing type is a three-digit code used to identify the category of service requested. Prior authorization requests will be returned without adjudication if no processing type is indicated. Element 4 Billing Provider s Medicaid Provider Number Enter the eight-digit Medicaid provider number of the billing provider. The provider number in this element must correspond with the provider name listed in Element 1. The correct suffix for a certified substance abuse day treatment program is 21. Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 21

Appendix 4 (Continued) SECTION II RECIPIENT INFORMATION Element 5 Recipient Medicaid ID Number Enter the recipient s 10-digit Medicaid identification number. Do not enter any other numbers or letters. Use the recipient s Medicaid identification card or the Medicaid Eligibility Verification System (EVS) to obtain the correct identification number. Element 6 Date of Birth Recipient Enter the recipient s date of birth in MM/DD/YY format (e.g., September 8, 1966, would be 09/08/66). Element 7 Address Recipient Enter the complete address of the recipient s place of residence, including the street, city, state, and zip code. If the recipient is a resident of a nursing home or other facility, include the name of the nursing home or facility. Element 8 Name Recipient Enter the recipient s last name, followed by his or her first name and middle initial. Use the EVS to obtain the correct spelling of the recipient s name. If the name or spelling of the name on the Medicaid identification card and the EVS do not match, use the spelling from the EVS. Element 9 Sex Recipient Enter an X in the appropriate box to specify male or female. SECTION III DIAGNOSIS / TREATMENT INFORMATION Element 10 Diagnosis Primary Code and Description Enter the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code and description most relevant to the service requested. Element 11 Start Date SOI (not required) Element 12 First Date of Treatment SOI (not required) Appendix Element 13 Diagnosis Secondary Code and Description Enter the appropriate secondary ICD-9-CM diagnosis code and description relevant to the service requested, if applicable. Element 14 Requested Start Date Enter the requested start date for service(s) in MM/DD/YY format, if a specific start date is requested. If backdating is requested, include the clinical rationale for starting before PA was received. Backdating is not allowed on subsequent PA requests. The maximum backdating allowed is five working days from the date of receipt at Wisconsin Medicaid. Element 15 Performing Provider Number (not required) Element 16 Procedure Code Enter the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code for each service requested. Element 17 Modifiers Enter the modifier(s) corresponding to the procedure code listed, if a modifier is required by Wisconsin Medicaid. 22 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Appendix Appendix 4 (Continued) Element 18 POS Enter the appropriate two-digit place of service code designating where the requested service would be provided. Element 19 Description of Service Enter a written description corresponding to the appropriate HCPCS procedure code for each service requested. Element 20 QR Enter the appropriate quantity (e.g., hours) requested for each procedure code listed. Element 21 Charge Enter the usual and customary charge for each service requested. If the quantity is greater than 1, multiply the quantity by the charge for each service requested. Enter the total amount in this element. Note: The charges indicated on the request form should reflect the provider s usual and customary charge for the service requested. Providers are reimbursed for authorized services according to the provider Terms of Reimbursement issued by the Department of Health and Family Services. Element 22 Total Charges Enter the anticipated total charge for this request. Element 23 Signature Requesting Provider The original signature of the provider requesting this service must appear in this element. Element 24 Date Signed Enter the month, day, and year the PA/RF was signed (in MM/DD/YY format). Do not enter any information below the signature of the requesting provider this space is reserved for Wisconsin Medicaid consultants and analysts. Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 23

Appendix 24 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Appendix 5 Sample Prior Authorization Request Form (PA/RF) for Substance Abuse Day Treatment Services DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 11018 (Rev. 10/03) WISCONSIN MEDICAID PRIOR AUTHORIZATION REQUEST FORM (PA/RF) STATE OF WISCONSIN HFS 106.03(4), Wis. Admin. Code Providers may submit prior authorization (PA) requests by fax to Wisconsin Medicaid at (608) 221-8616; or, providers may send the completed form with attachments to: Wisconsin Medicaid, Prior Authorization, Suite 88, 6406 Bridge Road, Madison, WI 53784-0088. Instructions: Type or print clearly. Before completing this form, read your service-specific Prior Authorization Request Form (PA/RF) Completion Instructions. FOR MEDICAID USE ICN AT Prior Authorization Number SECTION I PROVIDER INFORMATION 1. Name and Address Billing Provider (Street, City, State, Zip Code) I.M. Provider 1 W. Wilson Anytown, WI 55555 2. Telephone Number Billing Provider (XXX) XXX-XXXX 4. Billing Provider s Medicaid Provider Number 00000021 1234567 3. Processing Type SECTION II RECIPIENT INFORMATION 5. Recipient Medicaid ID Number 6. Date of Birth Recipient 7. Address Recipient (Street, City, State, Zip Code) 1234567890 (MM/DD/YY) MM/DD/YY 609 Willow 8. Name Recipient (Last, First, Middle Initial) 9. Sex Recipient Anytown, WI 55555 Recipient, Im A! X M! F SECTION III DIAGNOSIS / TREATMENT ARCHIVAL INFORMATION USE ONLY 10. Diagnosis Primary Code and Description 11. Start Date SOI 12. First Date of Treatment SOI 303.90 alcohol dependence 13. Diagnosis Secondary Code and Description 14. Requested Start Date 305.20 cannabis abuse 15. Performing 16. Procedure Code 17. for Modifiers current 18. 19. Description policy of Service 20. QR 21. Charge Provider Number 1 2 3 4 POS H2012 HF 11 Behavioral health day treatment, per hour 64 XXX.XX 136 An approved authorization does not guarantee payment. Reimbursement is contingent upon eligibility of the recipient and provider at the time the service is provided and the completeness of the claim information. Payment will not be made for services initiated prior to approval or after the authorization expiration date. Reimbursement will be in accordance with Wisconsin Medicaid payment methodology and policy. If the recipient is enrolled in a Medicaid HMO at the time a prior authorized service is provided, Medicaid reimbursement will be allowed only if the service is not covered by the HMO. 22. Total Charges XXX.XX Appendix 23. SIGNATURE Requesting Provider 24. Date Signed MM/DD/YY FOR MEDICAID USE Procedure(s) Authorized: Quantity Authorized:! Approved Grant Date Expiration Date! Modified Reason:! Denied Reason:! Returned Reason: SIGNATURE Consultant / Analyst Date Signed Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 25

Appendix 26 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Appendix 6 Treatment Criteria for Substance Abuse Day Treatment (Adult): Severity of Illness Severity of Illness: Admission to Treatment Program Use the information in this appendix to complete the Prior Authorization/Substance Abuse Day Treatment Attachment (PA/SADTA), HCF 11037. Prior authorization criteria for intensity of treatment and severity of illness have been developed for substance abuse day treatment by Wisconsin Medicaid and substance abuse providers. The criteria illustrate the factors that will be used in determining whether substance abuse day treatment is considered medically necessary by Wisconsin Medicaid. Recipients must have at least one indicator from categories 1, 4, 5, and 6 and two indicators from categories 2 and 3: 1. Loss of control or relapse crisis (at least one): a. At the time of admission, imminent chemical use is likely without close monitoring and structured support. b. Recipient has a documented failure to maintain abstinence with a lower level of care. c. Relapse would result in grave physical or personal harm to the recipient. 2. Physical conditions or complications (two indicators): a. Recipient s physical condition will benefit from substance abuse day treatment. b. One of the following: " Recipient s physical condition is stable. " Recipient has physical problems sufficiently severe to trigger addictive behavior and thus requires substance abuse day treatment (e.g., chronic pain creating the urge to seek addictive drugs). 3. Psychiatric conditions or complications (two indicators): a. Recipient s psychiatric state will benefit from substance abuse day treatment. b. One of the following: " Recipient s psychiatric state is stable. " Recipient has psychological stressors sufficiently severe to result in the use of chemicals if he or she does not receive treatment within the structure of a day treatment program (e.g., depression, unresolved grief, physical or sexual abuse). 4. Recovery environment (at least one): a. Recipient s family environment or living situation is stable enough to permit benefit from day treatment. b. Family members and/or significant others are unsupportive of recovery goals. Recipient s focus on recovery is enhanced by leaving the home environment during the day, but he or she may return home because there is no active opposition by the family to the recovery effort. c. Instability of the recipient s living environment due to substance abuse may be remedied with substance abuse day treatment (e.g., threatened divorce). 5. Life areas impairment (at least one): a. Recipient s chemical abuse results in significant behavioral deterioration (e.g., abuse of significant other, dishonesty, criminal charges). b. Recipient s chemical abuse results in severe social dysfunction (e.g., breakdown of important personal relationships, financial irresponsibility). c. Recipient s chemical abuse results in substantial loss of vocational or educational performance (e.g., significant absenteeism, occupational difficulties, school suspension). 6. Treatment acceptance/resistance (at least one): a. Recipient lacks sufficient understanding of the addiction disease process to undertake her or his own recovery and is willing to undergo substance abuse day treatment. b. Recipient lacks sufficient personal responsibility for recovery to comply with a treatment program at a lower level of care and is willing to undergo substance abuse day treatment. Appendix Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 27

Appendix 28 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Appendix 7 Treatment Criteria for Substance Abuse Day Treatment Program (Adolescent): Severity of Illness Severity of Illness: Admission to Treatment Program Use the information in this appendix to complete the Prior Authorization/Substance Abuse Day Treatment Attachment (PA/SADTA), HCF 11037. Prior authorization criteria for intensity of treatment and severity of illness have been developed for substance abuse day treatment by Wisconsin Medicaid and substance abuse providers. The criteria illustrate the factors that will be used in determining whether substance abuse day treatment is considered medically necessary by Wisconsin Medicaid. Recipients must have at least one indicator from categories 1, 5, and 6 and two indicators from category 2; all indicators from categories 3 and 4 must be met: 1. Loss of control or relapse crisis (at least one): a. At the time of admission, imminent chemical use is likely without close monitoring and structured support. b. Recipient has a documented failure to maintain abstinence with a lower level of care. c. Relapse would result in grave physical or personal harm to recipient. 2. Physical conditions or complications (two indicators): a. Recipient s physical condition will permit benefit from substance abuse day treatment. b. One of the following: " Recipient s physical condition is stable. " Recipient has physical problems sufficiently severe to trigger addictive behavior and thus requires substance abuse day treatment (e.g., frequent headaches creating the urge to seek addictive drugs). 3. Psychiatric conditions or complications (all of the following): a. Recipient s psychiatric state is stable enough to permit benefit from substance abuse day treatment. b. Behaviors, if present, are related to chemical use problems rather than a psychiatric condition (e.g., negativistic behaviors, restlessness, sulkiness, grouchiness, verbal aggression, isolation from family activities). c. If changes in moods, feelings, or attitudes are observed, they are related to substance use rather than a separate condition (e.g., feelings of wanting to leave home, not being understood, lacking parental approval, not caring about personal appearance). d. Documentation of substance use great enough to damage emotional health. 4. Recovery environment (all of the following): a. Recipient s living situation and school environment are stable enough to permit benefit from substance abuse day treatment. b. Family conflicts related to the recipient s abuse may be remedied with day treatment (e.g., parents are resentful and angry about drug use). c. Other family issues that require attention, if present, can be addressed by the program staff or through appropriate referrals (e.g., conflicts between the parents). d. Parents, foster parents, or legal guardians are supportive of recovery goals. 5. Life areas impairment (at least one): a. Recipient s substance abuse results in significant behavioral deterioration (e.g., abusive behavior, dishonesty, delinquency, running away). b. Recipient s substance abuse results in obvious social dysfunction (e.g., breakdown of important personal relationships, financial irresponsibility, association with delinquent peer group). c. Recipient s substance abuse results in substantial loss of vocational or educational performance (e.g., significant absenteeism, school suspension, impaired school performance). Appendix Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 29

Appendix 6. Treatment acceptance/resistance (at least one): a. Recipient lacks sufficient understanding of the addiction disease process to undertake his or her own recovery and is willing to undergo substance abuse day treatment. b. Recipient lacks sufficient personal responsibility for recovery to comply with a treatment program at a lower level of care and is willing to undergo substance abuse day treatment. 30 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Appendix 8 Treatment Criteria for Substance Abuse Day Treatment Program (Adult and Adolescent): Intensity of Service Intensity of Service Use the information in this appendix to complete the Prior Authorization/Substance Abuse Day Treatment Attachment (PA/SADTA), HCF 11037. Prior authorization criteria for intensity of treatment and severity of illness have been developed for substance abuse day treatment by Wisconsin Medicaid and substance abuse providers. The criteria illustrate the factors that will be used in determining whether substance abuse day treatment is considered medically necessary by Wisconsin Medicaid. All of the criteria listed in this appendix must be met. Program Standards Treatment must take place in a certified substance abuse day treatment program offering a minimum of 60 hours of intensive outpatient services on a short-term basis. For example, a typical substance abuse day treatment program may run for three to five hours per day, three to five days per week, for four to six weeks. Diagnosis (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) 1. A physician has stated the recipient currently has a primary diagnosis of one of the following: a. 303.90 (alcohol dependence). b. 304.00-304.90 (drug dependence). In addition, diagnosis codes 305.00 and 305.20-305.90 (alcohol and other drug abuse) are acceptable primary diagnoses for adolescents 18 years and younger. 2. The recipient does not have a primary diagnosis by a physician of 291-292 (substance-induced psychotic disorders), 303.00 (alcohol intoxication), or 317-319 (mental retardation). Evaluation and Treatment 1. The PA request must indicate the recipient s history during at least the past 12 months of all treatment for substance abuse, including day treatment, other outpatient care, inpatient services, and detoxification, with dates of service. The request also must include a brief narrative on the recipient s previous substance abuse treatment outcomes. 2. If the recipient received any inpatient or day treatment services for substance abuse in the past 12 months, the request must explain why, in the opinion of the professional staff, the requested substance abuse day treatment program is necessary and effective. Such requests will receive intensive scrutiny by the Department of Health and Family Services, according to the following: a. Whether substance abuse day treatment is appropriate within the context of previous treatment. b. Whether substance abuse day treatment will have a more successful outcome than the previous treatments. c. Whether the intensity and design of the substance abuse day treatment program (frequency, duration, and length of sessions) are likely to achieve intended results. 3. The request must document the professional staff s judgment that the recipient has a reasonable potential to improve his or her likelihood of remaining substance free in a less structured environment after completion of substance abuse day treatment. 4. The treatment plan must contain measurable, active treatment goals and objectives. At a minimum, the plan must address goals related to the recipient s selected Severity of Illness indicators. 5. The treatment plan must note any special needs of the recipient, such as physical health conditions, secondary psychiatric disorders, learning disabilities, nutritional needs, parenting, leisure time needs, and legal status. The plan Appendix Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 31

Appendix must state how these needs have been assessed and what action has or will be taken to meet these needs in the context of substance abuse day treatment. The request must document that treatment efforts among various providers are coordinated, if the recipient is receiving treatment for other conditions or by other providers. 6. The treatment plan must do the following: a. Describe family involvement in treatment planning, if applicable. b. Contain a statement that the recipient agrees to maintain abstinence throughout the course of substance abuse day treatment. c. Include a plan for continuing care for six to 12 months after completion of substance abuse day treatment. 7. The treatment plan should encourage involvement in ongoing support programs such as self-help groups, if applicable. 32 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Appendix Appendix 9 Prior Authorization/Substance Abuse Day Treatment Attachment (PA/SADTA) Completion Instructions (A copy of the Prior Authorization/Substance Abuse Day Treatment Attachment [PA/SADTA] Completion Instructions is located on the following page.) Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 33

Appendix ARCHIVAL (This page was intentionally USE left ONLY blank.) 34 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 11037A (Rev. 06/03) STATE OF WISCONSIN WISCONSIN MEDICAID PRIOR AUTHORIZATION / SUBSTANCE ABUSE DAY TREATMENT ATTACHMENT (PA/SADTA) COMPLETION INSTRUCTIONS Wisconsin Medicaid requires certain information to enable Medicaid to authorize and pay for medical services provided to eligible recipients. Recipients are required to give providers full, correct, and truthful information for the submission of correct and complete claims for Medicaid reimbursement. This information should include, but is not limited to, information concerning eligibility status, accurate name, address, and Medicaid identification number (HFS 104.02[4], Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about Medicaid applicants and recipients is confidential and is used for purposes directly related to Medicaid administration such as determining eligibility of the applicant, processing prior authorization (PA) requests, or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of PA or Medicaid payment for the services. The use of this form is voluntary and providers may develop their own form as long as it includes all the information on this form and is formatted exactly like this form. If necessary, attach additional pages if more space is needed. Refer to the Substance Abuse Day Treatment section of the Mental Health and Substance Abuse Services Handbook for service restrictions and additional documentation requirements. Provide enough information for Wisconsin Medicaid medical consultants to make a reasonable judgment about the case. Attach the completed Prior Authorization/Substance Abuse Day Treatment Attachment (PA/SADTA), HCF 11037, to the Prior Authorization Request Form (PA/RF), HCF 11018, and physician prescription (if necessary) and send it to Wisconsin Medicaid. Providers may submit PA requests by fax to Wisconsin Medicaid at (608) 221-8616. Providers who wish to submit PA requests by mail may do so by submitting them to the following address: Wisconsin Medicaid Prior Authorization Ste 88 6406 Bridge Rd Madison WI 53784-0088 The provision of services that are greater than or significantly different from those authorized may result in nonpayment of the billing claim(s). SECTION I RECIPIENT INFORMATION Element 1 Name Recipient (Last, First, Middle Initial) Enter the recipient s name exactly as it appears on the recipient s Medicaid identification card. Element 2 Age Recipient Enter the age of the recipient in numerical form (e.g., 16, 21, 60). Element 3 Recipient Medicaid Identification Number Enter the recipient s 10-digit Medicaid identification number exactly as it appears on the recipient s Medicaid identification card. SECTION II PROVIDER INFORMATION Element 4 Name and Credentials Requesting / Performing Provider Enter the name and credentials of the therapist who will be providing treatment/service. Element 5 Telephone Number Requesting / Performing Provider Enter the performing provider s telephone number, including area code. Element 6 Name Referring / Prescribing Provider Enter the name of the provider referring/prescribing treatment. Element 7 Referring / Prescribing Provider s Medicaid Provider Number Enter the referring/prescribing provider s eight-digit provider number. The remaining portions of this attachment are to be used to document the justification for the service requested. Substance abuse day treatment is not a covered service for recipients who are residents of a nursing home or who are hospital inpatients.

PRIOR AUTHORIZATION / SUBSTANCE ABUSE DAY TREATMENT ATTACHMENT (PA/SADTA) COMPLETION INSTRUCTIONS Page 2 of 2 HCF 11037A (Rev. 06/03) SECTION III DOCUMENTATION Element 8 Describe the length and intensity of treatment requested. Include the anticipated beginning treatment date and estimated substance abuse day treatment discharge date, and attach a copy of treatment design. Element 9 List the dates of diagnostic evaluations or medical examinations and specific diagnostic procedures that were employed. Element 10 List the codes and descriptions from the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM) for the recipient s current primary and secondary diagnosis. Allowable DSM diagnoses are 303.90 (alcohol dependence), 304.00-304.90 (drug dependence), 305.00 (alcohol abuse), or 305.20-305.90 (other drug abuse, excluding caffeine intoxication). Element 11 Describe the recipient s current clinical problems and relevant clinical history, including substance abuse history. (Give details of dates of abuse, substance[s] abused, amounts used, date of last use, etc.) Element 12 Indicate whether or not the recipient has received any substance abuse treatment in the past 12 months. If the recipient has received substance abuse treatment within the past 12 months, indicate the date of each treatment episode, the type of service provided, and the treatment outcomes. Element 13 If the recipient received any inpatient substance abuse care, intensive outpatient substance abuse services, or substance abuse day treatment in the past twelve months, give rationale for appropriateness and medical necessity of the current request. Discuss projected outcome of additional treatment requested. Element 14 Describe the recipient s severity of illness using the indicators in a-f. Refer to the substance abuse day treatment criteria in the Substance Abuse Day Treatment section of the Mental Health and Substance Abuse Services Handbook. Element 15 Discuss the recipient s treatment plan and attach a copy of the plan. Element 16 Signature Recipient or Representative Signature of the recipient or representative indicates the signer has read the attached request for PA of substance abuse and agrees that it will be sent to Wisconsin Medicaid for review. Element 17 Date Signed Enter the month, day, and year the PA/SADTA was signed by the recipient or the recipient s representative (in MM/DD/YY format). Element 18 Relationship (if representative) Include relationship to recipient (if a representative signs). Element 19 Signature Performing Provider Enter the signature of the performing provider. Element 20 Date Signed Enter the month, day, and year the PA/SADTA was signed by the performing provider (in MM/DD/YY format). Element 21 Discipline of Performing Provider Enter the discipline of the performing provider. Element 22 Signature Supervising Physician or Psychologist Enter the signature of the supervising physician or psychologist. Element 23 Date Signed Enter the month, day, and year the PA/SADTA was signed by the supervising physician or psychologist (in MM/DD/YY format). Element 24 Supervising Physician or Psychologist s Medicaid Provider Number Enter the supervising physician or psychologist s Medicaid provider number.

Appendix Appendix 10 Prior Authorization/Substance Abuse Day Treatment Attachment (PA/SADTA) (for photocopying) [PA/SADTA] is located on the following pages.) (A copy of the Prior Authorization/Substance Abuse Day Treatment Attachment Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 37

Appendix ARCHIVAL (This page was intentionally USE left ONLY blank.) 38 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 11037 (Rev. 06/03) STATE OF WISCONSIN WISCONSIN MEDICAID PRIOR AUTHORIZATION / SUBSTANCE ABUSE DAY TREATMENT ATTACHMENT (PA/SADTA) Providers may submit prior authorization (PA) requests to Wisconsin Medicaid by fax at (608) 221-8616 or by mail to: Wisconsin Medicaid, Prior Authorization, Suite 88, 6406 Bridge Road, Madison, WI 53784-0088. Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Substance Abuse Day Treatment Attachment (PA/SADTA) Completion Instructions, HCF 11037A. SECTION I RECIPIENT INFORMATION 1. Name Recipient (Last, First, Middle Initial) 2. Age Recipient 3. Recipient Medicaid Identification Number SECTION II PROVIDER INFORMATION 4. Name and Credentials Requesting / Performing Provider 5. Telephone Number Requesting / Performing Provider 6. Name Referring / Prescribing Provider 7. Referring / Prescribing Provider s Medicaid Provider Number SECTION III DOCUMENTATION 8. Describe length and intensity of treatment requested. Program request is for hours per day, for for a total of days per week, weeks, hours. Anticipated beginning treatment date. Estimated substance abuse day treatment discharge date. Attach a copy of treatment design, which includes the following: a. A schedule of treatment (day, time of day, length of session, and service to be provided during that time). b. A brief description of aftercare / continuing care / follow-up component (also include this information in the treatment plan section of this form). 9. List the dates of diagnostic evaluations or medical examinations and specific diagnostic procedures that were employed. Continued

PRIOR AUTHORIZATION / SUBSTANCE ABUSE DAY TREATMENT ATTACHMENT (PA/SADTA) Page 2 of 4 HCF 11037 (Rev. 06/03) SECTION III DOCUMENTATION (Continued) 10. List the current primary and secondary diagnosis codes and descriptions from the most recent Diagnostic and Statistical Manual of Mental Disorders for the recipient s current primary and secondary diagnosis. 11. Describe the recipient s current clinical problems and relevant clinical history, including substance abuse history. (Give details of dates of abuse, substance[s] abused, amounts used, date of last use, etc.) 12. Has the recipient received any substance abuse treatment in the past twelve months? # Yes # No If Yes, provide information on the date of each treatment episode, the type of service provided, and the treatment outcomes. 13. Has the recipient received any inpatient substance abuse care, intensive outpatient substance abuse services, or substance abuse day treatment in the past twelve months? # Yes # No If Yes, give rationale for appropriateness and medical necessity of the current request. Discuss projected outcome of additional treatment requested. Continued

PRIOR AUTHORIZATION / SUBSTANCE ABUSE DAY TREATMENT ATTACHMENT (PA/SADTA) Page 3 of 4 HCF 11037 (Rev. 06/03) SECTION III DOCUMENTATION (Continued) 14. Describe the recipient s severity of illness using the following indicators. Individualize all information. a. Loss of control / relapse crisis. b. Physical conditions or complications. c. Psychiatric conditions or complications. (Include psychiatric diagnosis, medications, current psychiatric symptoms.) d. Recovery environment. e. Life areas impairment. (Specify social / occupational / legal / primary support group.) f. Treatment acceptance / resistance. 15. Treatment Plan Attach a copy of the recipient s substance abuse day treatment plan (refer to intensity of service guideline in the substance abuse day treatment criteria). Describe any special needs of the recipient and indicate how these will be addressed (for example, educational needs, access to treatment facility). Describe the recipient s family / personal support system. Indicate how these issues will be addressed in treatment, if applicable. If family members / personal support system are not involved in treatment, explain why not. Continued

PRIOR AUTHORIZATION / SUBSTANCE ABUSE DAY TREATMENT ATTACHMENT (PA/SADTA) Page 4 of 4 HCF 11037 (Rev. 06/03) SECTION III DOCUMENTATION (Continued) 15. Treatment Plan (Continued) Briefly describe treatment goals and objectives in specific and measurable terms. Describe the expected outcomes of treatment including the plan for continuing care. I have read the attached request for PA of substance abuse day treatment services and agree that it will be sent to Wisconsin Medicaid for review. 16. SIGNATURE Recipient or Representative 17. Date Signed 18. Relationship (if representative) Attach a photocopy of the physician s current prescription for substance abuse day treatment. (Must be dated within one month of receipt at Wisconsin Medicaid.) 19. SIGNATURE Performing Provider 20. Date Signed 21. Discipline of Performing Provider 22. SIGNATURE Supervising Physician or Psychologist 23. Date Signed 24. Supervising Physician or Psychologist s Medicaid Provider Number

Appendix 11 CMS 1500 Claim Form Instructions for Substance Abuse Day Treatment Services Use the following claim form completion instructions, not the claim form s printed descriptions, to avoid denial or inaccurate Medicaid claim payment. Complete all required elements as appropriate. Do not include attachments unless instructed to do so. Wisconsin Medicaid recipients receive a Medicaid identification card upon being determined eligible for Wisconsin Medicaid. Always verify a recipient s eligibility before providing nonemergency services by using the Medicaid Eligibility Verification System (EVS) to determine if there are any limitations on covered services and to obtain the correct spelling of the recipient s name. Refer to the Informational Resources section of the All-Provider Handbook or the Medicaid Web site for more information about the EVS. Submit completed paper claims to the following address: Wisconsin Medicaid Claims and Adjustments 6406 Bridge Rd Madison WI 53784-0002 Element 1 Program Block/Claim Sort Indicator Enter claim sort indicator P in the Medicaid check box for the service billed. Element 1a Insured s I.D. Number Enter the recipient s 10-digit Medicaid identification number. Do not enter any other numbers or letters. Use the Medicaid identification card or the EVS to obtain the correct identification number. Element 2 Patient s Name Enter the recipient s last name, first name, and middle initial. Use the EVS to obtain the correct spelling of the recipient s name. If the name or spelling of the name on the Medicaid identification card and the EVS do not match, use the spelling from the EVS. Element 3 Patient s Birth Date, Patient s Sex Enter the recipient s birth date in MM/DD/YY format (e.g., February 3, 1955, would be 02/03/55) or in MM/DD/YYYY format (e.g., February 3, 1955, would be 02/03/1955). Specify whether the recipient is male or female by placing an X in the appropriate box. Appendix Element 4 Insured s Name (not required) Element 5 Patient s Address Enter the complete address of the recipient s place of residence, if known. Element 6 Patient Relationship to Insured (not required) Element 7 Insured s Address (not required) Element 8 Patient Status (not required) Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 43

Appendix 11 (Continued) Element 9 Other Insured s Name Commercial health insurance must be billed prior to submitting claims to Wisconsin Medicaid, unless the service does not require commercial health insurance billing as determined by Wisconsin Medicaid. If the EVS indicates that the recipient has dental ( DEN ) or has no commercial health insurance, leave Element 9 blank. If the EVS indicates that the recipient has Wausau Health Protection Plan ( HPP ), BlueCross & BlueShield ( BLU ), Wisconsin Physicians Service ( WPS ), Medicare Supplement ( SUP ), TriCare ( CHA ), Vision only ( VIS ), a health maintenance organization ( HMO ), or some other ( OTH ) commercial health insurance, and the service requires other insurance billing according to the Coordination of Benefits section of the All-Provider Handbook, then one of the following three other insurance (OI) explanation codes must be indicated in the first box of Element 9. The description is not required, nor is the policyholder, plan name, group number, etc. (Elements 9a, 9b, 9c, and 9d are not required). Appendix Code OI-P OI-D OI-Y Description PAID by commercial health insurance or commercial HMO. In Element 29 of this claim form, indicate the amount paid by commercial health insurance to the provider or to the insured. DENIED by commercial health insurance or commercial HMO following submission of a correct and complete claim, or payment was applied towards the coinsurance and deductible. Do not use this code unless the claim was actually billed to the commercial health insurer. YES, the recipient has commercial health insurance or commercial HMO coverage, but it was not billed for reasons including, but not limited to: " The recipient denied coverage or will not cooperate. " The provider knows the service in question is not covered by the carrier. " The recipient s commercial health insurance failed to respond to initial and follow-up claims. " Benefits are not assignable or cannot get assignment. " Benefits are exhausted. Note: The provider may not use OI-D or OI-Y if the recipient is covered by a commercial HMO and the HMO denied payment because an otherwise covered service was not rendered by a designated provider. Services covered by a commercial HMO are not reimbursable by Wisconsin Medicaid except for the copayment and deductible amounts. Providers who receive a capitation payment from the commercial HMO may not submit claims to Wisconsin Medicaid for services that are included in the capitation payment. Element 10 Is Patient s Condition Related to (not required) Element 11 Insured s Policy, Group, or FECA Number Use the first box of this element for Medicare information. (Elements 11a, 11b, 11c, and 11d are not required.) Submit claims to Medicare before submitting claims to Wisconsin Medicaid. Element 11 should be left blank when one or more of the following statements is true: Medicare never covers the procedure in any circumstance. Wisconsin Medicaid indicates the recipient does not have any Medicare coverage including Medicare Cost ( MCC ) or Medicare + Choice ( MPC ) for the service provided. For example, the service is covered by Medicare Part A, but the recipient does not have Medicare Part A. Wisconsin Medicaid indicates that the provider is not Medicare enrolled. Medicare has allowed the charges. In this case, attach the Explanation of Medicare Benefits, but do not indicate on the claim form the amount Medicare paid. 44 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Appendix 11 (Continued) If none of the previous statements are true, a Medicare disclaimer code is necessary. The following Medicare disclaimer codes may be used when appropriate. Code Description M-5 Provider is not Medicare certified. This code may be used when providers are identified in Wisconsin Medicaid files as being Medicare certified, but are billing for dates of service (DOS) before or after their Medicare certification effective dates. Use M-5 in the following instances: For Medicare Part A (all three criteria must be met): " The provider is identified in Wisconsin Medicaid files as certified for Medicare Part A, but the provider was not certified for the date the service was provided. " The recipient is eligible for Medicare Part A. " The procedure provided is covered by Medicare Part A. For Medicare Part B (all three criteria must be met): " The provider is identified in Wisconsin Medicaid files as certified for Medicare Part B, but the provider was not certified for the date the service was provided. " The recipient is eligible for Medicare Part B. " The procedure provided is covered by Medicare Part B. M-7 Medicare disallowed or denied payment. This code applies when Medicare denies the claim for reasons related to policy (not billing errors), or the recipient's lifetime benefit, spell of illness, or yearly allotment of available benefits is exhausted. Use M-7 in the following instances: For Medicare Part A (all three criteria must be met): " The provider is identified in Wisconsin Medicaid files as certified for Medicare Part A. " The recipient is eligible for Medicare Part A. " The service is covered by Medicare Part A but is denied by Medicare Part A due to frequency limitations, diagnosis restrictions, or the service is not payable due to benefits being exhausted. For Medicare Part B (all three criteria must be met): " The provider is identified in Wisconsin Medicaid files as certified for Medicare Part B. " The recipient is eligible for Medicare Part B. " The service is covered by Medicare Part B but is denied by Medicare Part B due to frequency limitations, diagnosis restrictions, or the service is not payable due to benefits being exhausted. M-8 Noncovered Medicare service. This code may be used when Medicare was not billed because the service is not covered in this circumstance. Use M-8 in the following instances: For Medicare Part A (all three criteria must be met): " The provider is identified in Wisconsin Medicaid files as certified for Medicare Part A. " The recipient is eligible for Medicare Part A. " The service is usually covered by Medicare Part A but not in this circumstance (e.g., recipient's diagnosis). For Medicare Part B (all three criteria must be met): " The provider is identified in Wisconsin Medicaid files as certified for Medicare Part B. " The recipient is eligible for Medicare Part B. " The service is usually covered by Medicare Part B but not in this circumstance (e.g., recipient's diagnosis). Appendix Elements 12 and 13 Authorized Person s Signature (not required) Element 14 Date of Current Illness, Injury, or Pregnancy (not required) Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 45

Element 15 If Patient Has Had Same or Similar Illness (not required) Element 16 Dates Patient Unable to Work in Current Occupation (not required) Elements 17 and 17a Name and I.D. Number of Referring Physician or Other Source Enter the referring physician s name and six-character Universal Provider Identification Number (UPIN). If the UPIN is not available, enter the eight-digit Medicaid provider number or the license number of the referring physician. Element 18 Hospitalization Dates Related to Current Services (not required) Element 19 Reserved for Local Use (not required) Element 20 Outside Lab? (not required) Appendix 11 (Continued) Element 21 Diagnosis or Nature of Illness or Injury Enter the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for each symptom or condition related to the services provided. List the primary diagnosis first. Etiology ( E ) and manifestation ( M ) codes may not be used as a primary diagnosis. The diagnosis description is not required. Refer to Appendix 2 of this section for a list of diagnosis codes. Element 22 Medicaid Resubmission (not required) Element 23 Prior Authorization Number Enter the seven-digit prior authorization (PA) number from the approved Prior Authorization Request Form (PA/RF), HCF 11018. Services authorized under multiple PA requests must be billed on separate claim forms with their respective PA numbers. Wisconsin Medicaid will only accept one PA number per claim. Appendix Element 24A Date(s) of Service Enter the month, day, and year for each service using the following guidelines: When billing for one DOS, enter the date in MM/DD/YY or MM/DD/YYYY format in the From field. When billing for two, three, or four DOS on the same detail line, enter the first DOS in MM/DD/YY or MM/DD/ YYYY format in the From field and enter subsequent DOS in the To field by listing only the date(s) of the month. For example, for DOS on June 1, 8, 15, and 22, 2005, indicate 06/01/05 or 06/01/2005 in the From field and indicate 08/15/22 in the To field. It is allowable to enter up to four DOS per line if the following are true: All DOS are in the same calendar month. All services are billed using the same procedure code and modifier, if applicable. All services have the same place of service (POS) code. All services were performed by the same provider. The same diagnosis is applicable for each service. The charge for all services is identical. (Enter the total charge per detail line in Element 24F.) The number of services performed on each DOS is identical. All services have the same HealthCheck or family planning indicator, if applicable. All services have the same emergency indicator, if applicable. 46 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Appendix 11 (Continued) Element 24B Place of Service Enter the appropriate two-digit POS code for each service. See Appendix 3 for a list of allowable POS codes. Element 24C Type of Service (not required) Element 24D Procedures, Services, or Supplies Enter the single most appropriate five-character procedure code. Wisconsin Medicaid denies claims received without an appropriate procedure code. Modifiers Enter the appropriate (up to four per procedure code) modifier(s) in the Modifier column of Element 24D. Note: Wisconsin Medicaid has not adopted all national modifiers. Element 24E Diagnosis Code Enter the number (1, 2, 3, or 4) that corresponds to the appropriate ICD-9-CM diagnosis code listed in Element 21. Element 24F $ Charges Enter the total charge for each line item. Providers are required to bill Wisconsin Medicaid their usual and customary charge. The usual and customary charge is the provider s charge for providing the same service to persons not entitled to Medicaid benefits. Element 24G Days or Units Enter the appropriate number of units for each line item. All day treatment substance abuse services are one-hour procedure codes. When billing for fractions of an hour, indicate units of service in half-hour increments using the standard rules of rounding. Always use a decimal (e.g., 2.0 units). Minutes Billed Quantity 1-6.1 7-12.2 13-18.3 19-24.4 25-30.5 31-36.6 37-42.7 43-48.8 49-54.9 55-60 1.0 Appendix Element 24H EPSDT/Family Plan (not required) Element 24I EMG (not required) Element 24J COB (not required) Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 47

Element 24K Reserved for Local Use When the billing provider (Element 33) is a county/tribal social or human services agency biller only provider, enter the eight-digit individual performing provider number of the contracted agency providing the service. Otherwise, leave this element blank. Any other information entered in this element may cause claim denial. Element 25 Federal Tax I.D. Number (not required) Element 26 Patient s Account No. (not required) Optional Providers may enter up to 20 characters of the patient s internal office account number. This number will appear on the Remittance and Status Report and/or the 835 Health Care Claim Payment/Advice transaction. Element 27 Accept Assignment (not required) Element 28 Total Charge Enter the total charges for this claim. Appendix 11 (Continued) Element 29 Amount Paid Enter the actual amount paid by commercial health insurance. (If the dollar amount indicated in Element 29 is greater than zero, OI-P must be indicated in Element 9.) If the commercial health insurance denied the claim, enter 000. Do not enter Medicare-paid amounts in this field. Element 30 Balance Due Enter the balance due as determined by subtracting the amount paid in Element 29 from the amount in Element 28. Element 31 Signature of Physician or Supplier The provider or the authorized representative must sign in Element 31. The month, day, and year the form is signed must also be entered in MM/DD/YY or MM/DD/YYYY format. Note: The signature may be a computer-printed or typed name and date or a signature stamp with the date. Appendix Element 32 Name and Address of Facility Where Services Were Rendered (not required) Element 33 Physician s, Supplier s Billing Name, Address, ZIP Code, and Phone # Enter the name of the provider submitting the claim and the complete mailing address. The minimum requirement is the provider s name, city, state, and ZIP code. At the bottom of Element 33, enter the billing provider s eight-digit Medicaid provider number. 48 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Appendix 12 Sample CMS 1500 Claim Form for Substance Abuse Day Treatment Services P 1234567890 Recipient, Im A 609 Willow MM DD YY X Anytown WI 55555 XXX XXX-XXXX OI-P M-8 I.M. Referring MD 12345678 303.90 1234567 01 07 05 11 H2012 HF U6 1 XX XX 1.5 Appendix 01 12 05 11 H2012 HF 1 XX XX 1.0 01 14 05 21 28 11 H2012 HF 1 XX XX 3.0 1234JED XXX XX XX.XX XX XX I.M. Authorized MMDDYY I.M. Billing 1 W. Williams Anytown, WI 55555 87654321 Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 49

Appendix 50 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Appendix 13 Sample CMS 1500 Claim Form for Substance Abuse Day Treatment Services, Biller Only Providers P 1234567890 Recipient, Im A 609 Willow MM DD YY X Anytown WI 55555 XXX XXX-XXXX OI-P M-8 I.M. Referring MD 12345678 303.90 1234567 01 07 05 11 H2012 HF U6 1 XX XX 1.5 76543211 Appendix 01 12 05 11 H2012 HF 1 XX XX 1.0 76543211 01 14 05 21 28 11 H2012 HF 1 XX XX 3.0 76543211 1234JED XXX XX XX.XX XX XX I.M. Authorized MMDDYY I.M. County/Tribal Biller-Only 1 W. Williams Anytown, WI 55555 87654321 Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 51

Appendix 52 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Appendix 14 Mental Health and Substance Abuse Services Documentation Requirements Providers are responsible for meeting Medicaid s medical and financial documentation requirements. Refer to HFS 106.02(9)(a), Wis. Admin. Code, for preparation and maintenance documentation requirements and HFS 106.02(9)(c), Wis. Admin. Code, for financial records documentation requirements. The following are Wisconsin Medicaid s medical record documentation requirements (HFS 106.02[9][b], Wis. Admin. Code) as they apply to all mental health and substance abuse services. In each element, the applicable administrative code language is in parentheses. The provider is required to include the following written documentation in the recipient s medical record, as applicable: 1. Date, department, or office of the provider, as applicable, and provider name and profession. 2. Presenting problem (chief medical complaint or purpose of the service or services). 3. Assessments (clinical findings, studies ordered, and diagnosis or medical impression): a. Intake note signed by the therapist (clinical findings). b. Information about past treatment, such as where it occurred, for how long, and by whom (clinical findings). c. Mental status exam, including mood and affect, thought processes principally orientation X3, dangerousness to others and self, and behavioral and motor observations. Other information that may be essential depending on presenting symptoms includes thought processes other than orientation X3, attitude, judgment, memory, speech, thought content, perception, intellectual functioning, and general appearance (clinical findings/diagnosis or medical impression). d. Biopsychosocial history, which may include, educational or vocational history, developmental history, medical history, significant past events, religious history, substance abuse history, past mental health treatment, criminal and legal history, significant past relationships and prominent influences, behavioral history, financial history, and overall life adjustment (clinical findings). e. Psychological, neuropsychological, functional, cognitive, behavioral, and/or developmental testing as indicated (studies ordered). f. Current status, including mental status, current living arrangements and social relationships, support system, current activities of daily living, current and recent substance abuse usage, current personal strengths, current vocational and educational status, and current religious attendance (clinical findings). 4. Treatment plans, including treatment goals/objectives, which are expressed in behavioral terms that provide measurable indices of performance, planned intervention, mechanics of intervention (frequency, duration, responsible party[ies]) (disposition, recommendations, and instructions given to the recipient, including any prescriptions and plans of care or treatment provided). 5. Progress notes (therapies or other treatments administered) must provide data relative to accomplishment of the treatment goals in measurable terms. Progress notes also must document significant events that are related to the person s treatment plan and assessments and that contribute to an overall understanding of the person s ongoing level and quality of functioning. Appendix Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 53

Appendix 54 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006

Index Index Certification, 5, 15 Claims Submission coordination of benefits, 11 diagnosis codes, 11 electronic, 11 paper, 11 place of service codes, 11, 19 procedure codes, 11, 17 CMS 1500 Claim Form biller-only sample, 51 completion instructions, 43 sample, 49 Copayment, 5 Prior Authorization/Substance Abuse Day Treatment Attachment (PA/SADTA) completion instructions, 33 for photocopying, 37 Prior Authorization backdating, 9 criteria, 9 procedures, 9 services requiring, 9 Prior Authorization Request Form (PA/RF) completion instructions, 21 sample, 25 Reimbursement, 12 Covered Services, 7 Documentation requirements, 8, 53 time, 8 Managed Care Coverage, 5 Noncovered Services, 8 Reimbursement Limitations, 8 Requirements program admission, 7 sessions, 7 Substance Abuse Day Treatment treatment criteria, 27, 29, 31 Telehealth, 8 Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 55

Index 56 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006